New Patient Paperwork

Shenandoah Foot & Ankle Center is pleased to welcome you to the office. Please take a few minutes of your time to answer these questions to help us become better acquainted.

We will need the following information if the spouse, parent, and/or guardian is the insured or responsible party for the account and/or if the child is a minor.

As a courtesy, claims will be submitted to the insurance company, but we want you to understand that all account balances are patient/guardian responsibility. There may be some services that are not covered by the insurance company, and you will be responsible for those non-covered services, as well as co-payments, co-insurances and deductibles due. If the account is turned over to a collection agency, patient/guardian will also be responsible for any and all charges associated with the collection of the account which may also include attorney and court fees.

Permission is hereby given to Shenandoah Foot & Ankle Center, for examination and treatment of the individual described above. I fully understand that I am responsible for any copayments, coinsurances, deductibles and any noncovered services with my insurance company. Authorization is also given to release any information regarding the medical history to my medical benefits provider and/or physicians. Furthermore, I authorize payment of medical benefits directly to Shenandoah Foot & Ankle Center, for services rendered.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medical History

Please list all medications:

Please list all allergies:

Family History: (List the relationship of any blood relatives that have had any of the following.)

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I chose) and understand the Notice.

Shenandoah Foot & Ankle Center can discuss my medical and or financial information and release information to the following person(s):

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.